StructureDefinition-2.16.840.1.113883.10.20.22.1.8

Sourcehl7.cda.us.ccdar2dot2#current:Consolidated CDA Release 2.1 StructureDefinition Publication (v5.0.0)
resourceTypeStructureDefinition
id2.16.840.1.113883.10.20.22.1.8
canonicalhttp://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.8
version2.2
statusactive
publisherHealth Level Seven
nameDischargeSummary
titleDischarge Summary
date2021-11-24T17:43:01+00:00
descriptionThe Discharge Summary is a document which synopsizes a patient's admission to a hospital, LTPAC provider, or other setting. It provides information for the continuation of care following discharge. The Joint Commission requires the following information to be included in the Discharge Summary (http://www.jointcommission.org/): The reason for hospitalization (the admission) The procedures performed, as applicable The care, treatment, and services provided The patients condition and disposition at discharge Information provided to the patient and family Provisions for follow-up care The best practice for a Discharge Summary is to include the discharge disposition in the display of the header.
jurisdictionsus
fhirVersion4.0.1
kindresource
abstractfalse
sdTtypeClinicalDocument
derivationconstraint
basehttp://hl7.org/fhir/cda/ccda/StructureDefinition/2.16.840.1.113883.10.20.22.1.1
Usages(none)
Name Flags Card. Type Description & Constraints doco
. . ClinicalDocument USRealmHeader
. . . Slices for templateId Slice: Unordered, Open by value:root, value:extension
. . . . templateId:secondary C 1..1 1198-32938: When asserting this templateId, all C-CDA 2.1 section and entry templates that had a previous version in C-CDA R1.1 **SHALL** include both the C-CDA 2.1 templateId and the C-CDA R1.1 templateId root without an extension. See C-CDA R2.1 Volume 1 - Design Considerations for additional detail (CONF:1198-32938).
. . . . . root 1..1 Required Pattern: 2.16.840.1.113883.10.20.22.1.8
. . . . . extension 1..1 Required Pattern: 2015-08-01
. . . code 1..1 The Discharge Summary recommends use of a single document type code, 18842-5 "Discharge summary", with further specification provided by author or performer, setting, or specialty. When pre-coordinated codes are used, any coded values describing the author or performer of the service act or the practice setting must be consistent with the LOINC document type.
. . . . code 1..1 Binding: todo ( required )
. . . participant C 0..* The participant element in the Discharge Summary header follows the General Header Constraints for participants. Discharge Summary does not specify any use for functionCode for participants. Local policies will determine how this element should be used in implementations.
1198-8469: When participant/@typeCode is IND, associatedEntity/@classCode **SHALL** be selected from ValueSet 2.16.840.1.113883.11.20.9.33 INDRoleclassCodes STATIC 2011-09-30 (CONF:1198-8469).
. . . componentOf 1..1 The Discharge Summary is always associated with a Hospital Admission using the encompassingEncounter element in the header.
. . . . encompassingEncounter 1..1
. . . . . effectiveTime 1..1
. . . . . . low 1..1 The admission date is recorded in the componentOf/encompassingEncounter/effectiveTime/low.
. . . . . . high 1..1 The discharge date is recorded in the componentOf/encompassingEncounter/effectiveTime/high.
. . . . . dischargeDispositionCode 1..1 The dischargeDispositionCode records the disposition of the patient at time of discharge. Access to the National Uniform Billing Committee (NUBC) code system requires a membership. The following conformance statement aligns with HITSP C80 requirements. The dischargeDispositionCode, @displayName, or NUBC UB-04 Print Name, must be displayed when the document is rendered.
Binding: todo ( preferred )
. . . . . responsibleParty 0..1 The responsibleParty element represents only the party responsible for the encounter, not necessarily the entire episode of care.
. . . . . . assignedEntity C 1..1 1198-32898: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32898).
. . . . . encounterParticipant 0..* The encounterParticipant element represents persons who participated in the encounter and not necessarily the entire episode of care.
. . . . . . assignedEntity C 1..1 1198-32899: This assignedEntity **SHALL** contain an assignedPerson or a representedOrganization or both (CONF:1198-32899).
. . . component 1..1
. . . . structuredBody C 1..1 In this template (templateId 2.16.840.1.113883.10.20.22.1.8.2), coded entries are optional.
1198-30569: This structuredBody ***SHALL NOT*** contain a Chief Complaint and Reason for Visit Section (2.16.840.1.113883.10.20.22.2.13) when either a Chief Complaint Section (1.3.6.1.4.1.19376.1.5.3.1.1.13.2.1) or a Reason for Visit Section (2.16.840.1.113883.10.20.22.2.12) is present (CONF:1198-30569).
. . . . . Slices for component Slice: Unordered, Open by value:ClinicalDocument.section
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doco Documentation for this format

Produced 08 Sep 2023